The Index of Microcirculatory Resistance as a Predictor of Echocardiographic Left Ventricular Performance Recovery in Patients With ST-Elevation Acute Myocardial Infarction Undergoing Successful Primary Angioplasty.

BACKGROUND: This study aims to evaluate the relationship between IMR (Index of Microcirculatory Resistance) and the echocardiographic evolution of left ventricular (LV) systolic and diastolic performance after ST-elevation acute myocardial infarction (STEMI), undergoing primary angioplasty (P-PCI). METHODS: IMR was evaluated immediately after P-PCI. Echocardiograms were performed within the first 24 hours (Echo1) and at 3 months (Echo2): LV volumes, ejection fraction (LVEF), wall motion score index (WMSI), E/é ratio, global longitudinal strain (GLS), and left atrial volume were measured. RESULTS: Forty STEMI patients were divided in 2 groups according to median IMR: Group 1 (IMR < 26), with less microvascular dysfunction, and Group 2 (IMR > = 26), with more microvascular dysfunction. In Echo1 GLS was significantly better in Group 1 (-14.9 vs. -12.9 in Group 2, P = 0.005). However, there were no significant differences between the two groups in LV systolic volume, LVEF and WMS. Between Echo1 and Echo2, there were significant improvements in LVEF (0.48 ± 0.06 vs. 0.55 ± 0.06, P < 0.0001), GLS (-14.9 ± 1.3 vs. -17.3 ± 7.6, P = 0.001), and E/é ratio (9.3 ± 3.4 vs. 8.2 ± 2.0, P = 0.037) in Group 1, but not in Group 2: LVEF (0.49 ± 0.06 vs. 0.50 ± 0.05, P = 0.47), GLS (-12.9 ± 2.4 vs. -14.4 ± 3.2, P = 0.052), and E/é ratio (8.8 ± 2.4 vs. 10.0 ± 4.7, P = 0.18). WMSI improved significantly more in Group 1 (reduction of -17.1% vs. -6.8% in Group 2, P = 0.015). CONCLUSION: Lower IMR was associated with better myocardial GLS acutely after STEMI, and with a significantly higher recovery of the LVEF, WMSI, E/E' ratio and GLS, suggesting that IMR is an early marker of cardiac recovery, after acute myocardial infarction.

Impact of the COVID-19 pandemic on percutaneous coronary interventions in Portugal.

INTRODUCTION: The COVID-19 pandemic has imposed an unprecedented burden on healthcare systems worldwide, changing the profile of interventional cardiology activity. OBJECTIVES: To quantify and compare the number of percutaneous coronary interventions (PCIs) performed for acute and chronic coronary syndromes during the first COVID-19 outbreak with the corresponding period in previous years. METHODS: Data on PCI from the prospective multicenter Portuguese Registry on Interventional Cardiology (RNCI) were used to analyze changes in PCI for ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndromes (NSTE-ACS) and chronic coronary syndromes (CCS). The number of PCIs performed during the initial period of the COVID-19 outbreak in Portugal, from March 1 to May 2, 2020, was compared with the mean frequency of PCIs performed during the corresponding period in the previous three years (2017-2019). RESULTS: The total number of PCIs procedures was significantly decreased during the initial COVID-19 outbreak in Portugal (-36%, p<0.001). The reduction in PCI procedures for STEMI, NSTE-ACS and CCS was, respectively, -25% (p<0.019), -20% (p<0.068) and -59% (p<0.001). CONCLUSIONS: Compared with the corresponding period in the previous three years, the number of PCI procedures performed for STEMI and CCS decreased markedly during the first wave of the COVID-19 pandemic in Portugal.

Temporal trends in referral patterns for invasive coronary angiography - a multicenter 10-year analysis.

AIM: To assess the temporal trends in the usage pattern of non-invasive testing before invasive coronary angiography (ICA) and its diagnostic yield in patients with suspected coronary artery disease (CAD). METHODS: Cross-sectional observational multicenter study of 4805 consecutive patients (60% male, mean age 66 ± 10 years) with suspected CAD undergoing elective ICA due to angina pectoris in two centers, from 2008 to 2017. The use of noninvasive testing and the proportion of patients with obstructive CAD (defined as the presence of at least one ≥50% stenosis on ICA) were assessed. RESULTS: There were 4038 (84%) patients referred for ICA with positive noninvasive test, mainly SPECT (38%, n = 1828) and exercise ECG (36%, n = 1731). Obstructive CAD was found in 54.5% (n = 2621) of the patients and 37.9% (n = 1822) underwent revascularization. The prevalence of obstructive CAD was higher in patients with vs. without previous noninvasive testing (55.8% vs. 48.1%, respectively, P < 0.001) and tended to decrease during the study period (P for trend <0.001). Both the presence of obstructive CAD and revascularization rate were higher in patients who underwent anatomical evaluation with CCTA compared with noninvasive functional tests (P = 0.001 and P = 0.018, respectively). The number of patients referred after exercise testing and SPECT decreased (p for trend 0.005 and 0.006, respectively) and after CCTA and stress CMR increased (both P for trend <0.001). The proportion of patients referred without previous testing remained stable. CONCLUSION: Nearly half of the patients undergoing ICA for suspected CAD did not have obstructive coronary lesions. This proportion tended to increase over the 10-year span of this study. Better clinical assessment tools and diagnostic pathways for stable CAD are warranted.

Five-year clinical results of coronary angioplasty with drug-eluting stents. National initiative in strategic innovation, iNOS.

INTRODUCTION: The use of drug-eluting stents (DES) is beneficial in patients undergoing percutaneous coronary intervention (PCI) and there is particular interest in long-term follow-up. OBJECTIVE: We aimed to assess and characterize early DES use in Portugal during 2003 and patient follow-up over a 5-year period. We developed a web-based database to collect and organize patient and procedural data from PCI performed in ten cardiovascular interventional centers sharing the same database. METHODS: This was a multicenter retrospective study that included 1833 consecutive angiographically successful coronary angioplasties in which a DES was implanted in 2003. A subgroup of patients with 5-year clinical follow-up after the initial procedure was selected for which there was at least a 90% follow-up rate during one quarter of 2003. Demographic, clinical and angiographic characteristics of the entire population were assessed. In the clinical follow-up cohort, the incidence of major adverse cardiac events (MACE)--death, myocardial infarction and surgical or percutaneous target lesion revascularization--was analyzed by survival curves and logistic regression analysis. RESULTS: Of the total population, 23% were female, and mean age was 62 +/- 11 years (25-92). The main risk factors were hypertension (60.5%), dyslipidemia (42.9%), smoking (45.1%) and diabetes (23.9%, of whom 13.2% were on insulin therapy). There was a history of myocardial infarction, PCI or bypass surgery respectively in 23.1%, 25.1%, and 9.7% of the patients. Multivessel disease was present in 59.9% of patients (mean of 1.86 +/- 0.81 vessels). PCI was performed on average in 1.24 +/- 0.48 lesions, and complete revascularization in 58.8%. A total of 2058 stents were used (mean of 1.62 +/- 0.84) in 1271 patients. The longitudinal substudy included only 320 PCIs, for which follow-up was achieved in 319 (99%; median: 1875 days, P25: 1457 days, P75: 2045 days). Thirty-seven deaths (11.6%) and 61 MACE (19.1%) occurred in this group, with no differences between insulin-treated and other diabetic patients. CONCLUSION: This is the first study to analyze the early Portuguese experience with drug-eluting stents. The clinical results compare favorably with the first published international registries. The on-line platform used was successful in collecting data in a standardized format on the clinical experience of multiple centers.

Fifteen years of coronary intravascular ultrasound in percutaneous coronary intervention in Portugal. / Quinze anos de ecografia intravascular coronária em intervenção coronária percutânea em Portugal.

INTRODUCTION: Coronary intravascular ultrasound (IVUS) is increasingly important in catheterization laboratories due to its positive prognostic impact. This study aims to characterize the use of IVUS in percutaneous coronary intervention (PCI) in Portugal. METHODS: A retrospective observational study was performed based on the Portuguese Registry on Interventional Cardiology of the Portuguese Society of Cardiology. The clinical and angiographic profiles of patients who underwent PCI between 2002 and 2016, the percentage of IVUS use, and the coronary arteries assessed were characterized. RESULTS: A total of 118 706 PCIs were included, in which IVUS was used in 2266 (1.9%). Over time, use of IVUS changed from none in 2002 to generally increasing use from 2003 (0.1%) to 2016 (2.4%). The age of patients in whom coronary IVUS was used was similar to that of patients in whom IVUS was not used, but in the former group there were fewer male patients, and a higher prevalence of cardiovascular risk factors (hypertension, hypercholesterolemia and diabetes), previous myocardial infarction, previous PCI, multivessel coronary disease, C-type or bifurcated coronary lesions, and in-stent restenosis. IVUS was used in 54.8% of elective PCIs and in 19.15% of PCIs of the left main coronary artery. CONCLUSION: Coronary IVUS has been increasingly used in Portugal since 2003. It is used preferentially in elective PCIs, and in patients with higher cardiovascular risk, with more complex coronary lesions and lesions of the left main coronary artery.

Combined myocardial infarction: two case reports.

Combined myocardial infarction is defined as a current of injury on the electrocardiogram in both inferior and anterior leads. From a pathophysiological standpoint, this indicates simultaneous acute transmural ischemia of contralateral vascular territories. The authors present the cases of two patients admitted with this rare type of infarction, followed by a discussion of the relationship between electrocardiographic and angiographic findings and their value for assessing prognosis in this clinical entity.

Ischemic stroke complicating cardiac catherization: case report.

Ischemic stroke occurs in 0.2-0.4% of patients undergoing left heart catheterization, and is responsible for 5-10% of the mortality associated with the procedure. The main predisposing factors for this complication are female gender, complex atherosclerotic plaques in the ascending aorta, and peripheral arterial disease. The possibility of timely intervention with reperfusion therapy supports close clinical monitoring during the immediate post-catheterization period. The cardiologist should be familiar with the various types of stroke reperfusion therapy and its indications according to the time interval between catheterization and the stroke. The decision should be discussed with neurology and neuroradiology.

Early peripheral endothelial dysfunction predicts myocardial infarct extension and microvascular obstruction in patients with ST-elevation myocardial infarction.

INTRODUCTION AND OBJECTIVES: The role of endothelial dysfunction (ED) in patients with ST-elevation myocardial infarction (STEMI) is poorly understood. Peripheral arterial tonometry (PAT) allows non-invasive evaluation of ED, but has never been used for this purpose early after primary percutaneous coronary intervention (P-PCI). Our purpose was to analyze the relation between ED assessed by PAT and both the presence of microvascular obstruction (MVO) and infarct extension in STEMI patients. METHODS: ED was assessed by the reactive hyperemia index (RHI), measured by PAT and defined as RHI <1.67. Infarct extension was assessed by troponin I (TnI) release and contrast-enhanced cardiac magnetic resonance (ceCMR). MVO was assessed by ceCMR and by indirect angiographic and ECG indicators. An echocardiogram was also performed in the first 12 h. RESULTS: We included 38 patients (mean age 60.0±13.7 years, 29 male). Mean RHI was 1.87±0.60 and 16 patients (42.1%) had ED. Peak TnI (median 118 mg/dl, IQR 186 vs. 67/81, p=0.024) and AUC of TnI (median 2305, IQR 2486 vs. 1076/1042, p=0.012) were significantly higher in patients with ED, who also showed a trend for more transmural infarcts (63.6% vs. 22.2%, p=0.06) and larger infarct mass on ceCMR (median 17.5%, IQR 15.4 vs. 10.1/10.3, p=0.08). Left ventricular ejection fraction (LVEF) was lower and wall motion score index (WMSI) was higher on both echocardiogram and ceCMR in patients with ED. On ceCMR, MVO was more frequent in patients with RHI <1.67 (54.5% vs. 11.1%, p=0.03). ECG and angiographic indicators of MVO all showed a trend toward worse results in these patients. CONCLUSIONS: The presence of ED assessed by PAT 24 h after P-PCI in patients with STEMI is associated with larger infarcts, lower LVEF, higher WMSI and higher prevalence of MVO.

Portugal: coronary and structural heart interventions from 2010 to 2015.

The aim of the present paper is to report trends in Portuguese interventional cardiology from 2010 to 2015. We studied data from the prospective multicentre Portuguese National Registry of Interventional Cardiology (RNCI) to analyse percutaneous coronary intervention (PCI) procedures and structural heart interventions from 2010 to 2015. A total of 73,977 PCIs and 780 transcatheter aortic valve implants were performed during the study period. Since 2010 there has been a 60% increase in PCI procedures and a twofold increase in primary angioplasty rates reaching 316 per million population. Significant PCI trends were observed, notably the increase of radial access, a reduction in restenosis indications, as well as an increase in stent use, including DES, in imaging and in functional techniques. Importantly, there was a fourfold increase in the TAVI rates reaching 29 per million population.

Trends in primary angioplasty in Portugal from 2002 to 2013 according to the Portuguese National Registry of Interventional Cardiology. / Angioplastia primária em Portugal entre 2002-2013. Atividade segundo o Registo Nacional de Cardiologia de Intervenção.

INTRODUCTION AND OBJECTIVES: The aim of the present paper was to report trends in coronary angioplasty for the treatment of ST-elevation myocardial infarction (STEMI) in Portugal. METHODS: Prospective multicenter data from the Portuguese National Registry of Interventional Cardiology (RNCI) and official data from the Directorate-General for Health (DGS) were studied to analyze percutaneous coronary intervention (PCI) procedures for STEMI from 2002 to 2013. RESULTS: In 2013, 3524 primary percutaneous coronary intervention (p-PCI) procedures were performed (25% of all procedures), an increase of 315% in comparison to 2002 (16% of all interventions). Between 2002 and 2013 the rate increased from 106 to 338 p-PCIs per million population per year. Rescue angioplasty decreased from 70.7% in 2002 to 2% in 2013. During this period, the use of drug-eluting stents grew from 9.9% to 69.5%. After 2008, the use of aspiration thrombectomy increased, reaching 46.7% in 2013. Glycoprotein IIb-IIIa inhibitor use decreased from 73.2% in 2002 to 23.6% in the last year of the study. Use of a radial approach increased steadily from 8.3% in 2008 to 54.6% in 2013. CONCLUSION: During the reporting period there was a three-fold increase in primary angioplasty rates per million population. Rescue angioplasty has been overtaken by p-PCI as the predominant procedure since 2006. New trends in the treatment of STEMI were observed, notably the use of drug-eluting stents and radial access as the predominant approach.

Three-dimensional contrast-enhanced magnetic resonance pulmonary angiography in the study of pulmonary vascular pathology.

OBJECTIVES: To assess the feasibility of performing pulmonary angiography using MRI with contrast enhancement in patients with pulmonary vascular disease. METHODS: We present our experience in ten individuals, two controls and eight patients who underwent the exam after injection of a gadolinium-based contrast agent on a 1 Tesla MR scanner using a time-of-flight sequence and breath-holding during injection of contrast. RESULTS: Pathology in the main pulmonary artery and its major branches was detected easily while resolution at the segmental and subsegmental levels was inadequate. CONCLUSION: Contrast-enhanced magnetic resonance pulmonary angiography is feasible on a 1 Tesla MR scanner for the study of pathology of the main pulmonary artery and its major branches, like massive pulmonary embolism. However its ability to detect and define distal vessel pathology as found in chronic thromboembolic pulmonary hypertension and small pulmonary emboli is limited.

Simultaneous catheterization of the coronary arteries in the treatment of chronic total occlusions.

Chronic total occlusions present technical challenges to the interventional cardiologist, and are accompanied by an increased propensity for complications. We present an argument for the routine use of simultaneous bilateral coronary angiography to help define the lesion and optimize the therapeutic approach. Eight selected cases of CTO were revascularized using this technique resulting in immediate procedural success, devoid of complications, in all cases.

Inter-hospital transfer of critically-ill patients for urgent cardiac surgery after placement of an intra-aortic balloon pump.

METHODS: To assess the safety and feasibility of transfer of patients requiring urgent cardiac surgery, from a hospital without onsite cardiac surgical facilities, after insertion of an intra-aortic balloon pump (IABP) to maintain clinical and hemodynamic stability, a retrospective review of all cardiac charactheterizations was performed. Sixty-two patients required IABPs, among whom 24 were transported to a surgical center from the outskirts of Lisbon to the city center in an ambulance accompanied by a physician, a nurse and paramedical personnel. RESULTS: Patients who required hemodynamic support with IABPs usually had unstable angina with critical coronary lesions requiring immediate surgical intervention, hypotensive patients with mechanical complications after an AMI, and patients with AMI who did not receive thrombolytic therapy, and with coronary lesions not amenable to percutaneous coronary intervention. All patients reached the surgical center alive, and no patient had either hemodynamic or electrical instability during transport. CONCLUSIONS: Surface transport of patients requiring emergency cardiac surgery after insertion of IABPs is safe, feasible and may provide circulatory and clinical stability in a subset of critically-ill patients.

Electrocardiographic identification of the infarct-related artery in acute inferior myocardial infarction.

INTRODUCTION: Mortality and morbidity from acute inferior myocardial infarction (MI) are determined, among other factors, by the infarct-related artery (IRA). Several electrocardiographic (ECG) criteria have been proposed to differentiate between the right coronary artery (RCA) and the left circumflex coronary artery (LCx) as the IRA in inferior MI. Recently, a new criterion has been proposed (ST segment depression in lead aVR). It was our objective to evaluate the old and the new ECG criteria in identifying the IRA in patients with inferior MI. METHODS: Patients with inferior MI treated by primary angioplasty were included, following evaluation of the admission ECG. Patients with a previous history of Q-wave myocardial infarction and complete bundle branch block were excluded. The artery with the most severe lesion was considered the IRA. The following ECG criteria were assessed: ST depression in lead DI; ST depression in leads V1 and V2, ST elevation in lead DIII > DII, ST depression in V3/ST elevation in DIII ratio > 1.2 (classical criteria) and ST depression in lead aVR. ST-segment elevation or depression was measured 0.06 sec after the J point. RESULTS: 53 patients were included (mean age 59.1 +/- 13.9 years, 38 males). The RCA was the IRA in 38 patients and the LCx in 15. Baseline characteristics (age, gender, TIMI flow, Killip class, and pain-to-balloon time) were similar in both groups. All the classical criteria were able to identify the IRA. The new criterion--ST depression in lead aVR--identified the IRA in a small number of patients (sensitivity 33%, specificity 71%, p = NS). CONCLUSIONS: The 4 classical criteria were useful in identifying the IRA in patients with inferior MI. ST depression in lead aVR (a recently proposed new criterion), on the other hand, showed limited utility in differentiating between RCA and LCx.

PAMI risk score for mortality prediction in acute myocardial indarction treated with primary angioplasty.

OBJECTIVE: Based on the PAMI 1 and 2, AIR PAMI, and STENT PAMI trials, a risk score to predict mortality in patients undergoing primary angioplasty was recently proposed--the PAMI risk score. It includes only 6 parameters. As one of the first tools available to predict mortality in this group of patients, it results from controlled trials, with restricted inclusion criteria. It was our objective to evaluate how the PAMI risk score applies to "real world" patients. METHODS: 149 patients (mean age 58.2 +/- 13.6 years, 113 male) undergoing primary angioplasty were included. The PAMI risk score was applied and the patients were divided in 3 groups: 0 to 2 points (group A), 3 to 6 points (group B) and > or =7 points (group C). RESULTS: Sixty-eight patients (46%) were included in group A, 41 (27%) in group B and 40 (27%) in group C. There were no significant differences in pain-to-balloon times between the 3 groups. Immediate mortality (0%, 2.4% and 15%: p = 0.001), in-hospital mortality (2.9%, 7.3% and 37.5%; p < 0.001), 30-day mortality (2.9%, 7.3% and 37.5%; p < 0.001) and 6-month mortality (4.4%, 14.6% and 45%; p < 0.001) were significantly different between the 3 groups. CONCLUSIONS: The PAMI risk score is a simple prognostic tool, with parameters that can be easily acquired, enabling reliable prediction of immediate, in-hospital, 30-day and 6-month mortality in patients with acute myocardial infarction treated with primary angioplasty.

Acute coronary syndrome of paradoxical origin.

We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism. A 44-year-old woman presented to the emergency department with chest pain. The physical examination was unremarkable except for oxygen saturation of 75%, and the electrocardiogram showed ST-segment elevation in the inferior leads. Urgent coronary angiography showed a distal occlusion of the right coronary artery and multiple thrombi were aspirated. Despite relief of chest pain and electrocardiogram normalization, her oxygen saturation remained low (90%) with high-flow oxygen by mask. The transthoracic echocardiogram showed a mass in the left atrium and dilatation of the right chambers, while the transesophageal echocardiogram showed a thrombus attached to the interatrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale. Thoracic computed tomography angiography documented thrombi in both branches of the pulmonary trunk. After five days on anticoagulation, the patient underwent surgical foramen ovale closure.

[Position statement on bioresorbable vascular scaffolds in Portugal]. / Posição sobre suportes vasculares restaurativos transitórios coronários em Portugal.

BACKGROUND: Bioresorbable vascular scaffolds (BVS) were recently approved for percutaneous coronary intervention in Europe. The aim of this position statement is to review the information and studies on available BVS, to stimulate discussion on their use and to propose guidelines for this treatment option in Portugal. METHODS AND RESULTS: A working group was set up to reach a consensus based on current evidence, discussion of clinical case models and individual experience. The evidence suggests that currently available BVS can produce physiological and clinical improvements in selected patients. There are encouraging data on their durability and long-term safety. Initial indications were grouped into three categories: (a) consensual and appropriate - young patients, diabetic patients, left anterior descending artery, long lesions, diffuse disease, and hybrid strategy; (b) less consensual but possible - small collateral branches, stabilized acute coronary syndromes; and (c) inappropriate - left main disease, tortuosity, severe calcification. CONCLUSION: BVS are a viable treatment option based on the encouraging evidence of their applicability and physiological and clinical results. They should be used in appropriate indications and will require technical adaptations. Outcome monitoring and evaluation is essential to avoid inappropriate use. It is recommended that medical societies produce clinical guidelines based on high-quality registries as soon as possible.